Provider Demographics
NPI:1780054817
Name:PAVLICA, JONATHAN GARY (DPT)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:GARY
Last Name:PAVLICA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BOWDEN LN
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-2201
Mailing Address - Country:US
Mailing Address - Phone:516-457-5773
Mailing Address - Fax:
Practice Address - Street 1:123 SOUTH ST STE 110
Practice Address - Street 2:
Practice Address - City:OYSTER BAY
Practice Address - State:NY
Practice Address - Zip Code:11771-2274
Practice Address - Country:US
Practice Address - Phone:516-624-6739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039152225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist